Provider Demographics
NPI:1649279860
Name:WATERMAN, SHANNON URSULA (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:URSULA
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E 26TH STREET
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98421
Mailing Address - Country:US
Mailing Address - Phone:253-722-1540
Mailing Address - Fax:253-722-1546
Practice Address - Street 1:11225 PACIFIC AVENUE
Practice Address - Street 2:PARKLAND CLINIC COMMUNITY HEALTHCARE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444
Practice Address - Country:US
Practice Address - Phone:253-536-2020
Practice Address - Fax:253-536-5327
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025209MD00041909208600000X
WAMD00041919208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8505422Medicaid
NM41383885Medicaid
P00707652OtherMEDICARE RAILROAD
NM41383885Medicaid
P00707652OtherMEDICARE RAILROAD
I01237Medicare UPIN